Effectiveness of Stroke Unit Care: A Special Report · Effectiveness of Stroke Unit Care: A Special Report. October 2014; pp. 1–42 6 Plain Language Summary A stroke is a sudden

Effectiveness of Stroke Unit Care: A Special Report. October 2014; pp. 1–42

Effectiveness of Stroke Unit Care:

A Special Report

Health Quality Ontario

October 2014

Effectiveness of Stroke Unit Care: A Special Report. October 2014; pp. 1–42 2

Suggested Citation

This report should be cited as follows:

Health Quality Ontario. Effectiveness of stroke unit care: a special report [Internet]. Toronto: Queen’s Printer for

Ontario; 2014 October. 42 p. Available from: http://www.hqontario.ca/evidence/publications-and-ohtac-

recommendations/other-reports/special-reports.

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Abstract

Background

A stroke is a sudden loss of brain function caused by either the interruption of blood flow to the brain

(ischemic stroke) or the rupture of blood vessels within the brain (hemorrhagic stroke). Approximately

80% of strokes are ischemic and 20% are hemorrhagic.

Objective

To determine the effectiveness of a stroke unit compared with a general medical ward for the

management of stroke.

Data Sources

A literature search was performed using Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-

Indexed Citations, OVID Embase, EBSCO Cumulative Index to Nursing & Allied Health Literature

(CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and Dissemination database, for

studies published from January 1, 2006, until December 6, 2011.

Review Methods

Abstracts were reviewed by a single reviewer, and full-text articles were obtained for studies meeting the

eligibility criteria. Where appropriate, a meta-analysis was undertaken for explicit outcomes to determine

the pooled estimate of effect of a stroke unit compared with a general medical ward. The degree of

statistical heterogeneity among studies was assessed using the I2 statistic for each outcome. The quality of

evidence was assessed according to the GRADE Working Group criteria.

Results

One relevant Cochrane systematic review was obtained from the literature search, from which 11

randomized controlled trials met the inclusion criteria. Moderate quality evidence showed that, compared

to persons admitted to a general medical ward, those admitted to a stroke unit had a 19% reduction in

death, a 20% reduction in death or institutionalization, and a 21% reduction in institutionalization. Low

quality evidence showed that there was a 13% reduction in death or dependency, and a 12-day reduction

in the length of hospital stay in persons admitted to a stroke unit.

Limitations

Published data were extracted from original reports. Unpublished data reported in the 2009 Cochrane

review were included in the meta-analysis.

Conclusions

Moderate quality evidence showed that persons admitted to a stroke unit had a significant reduction in

death and the combined outcome of death or institutionalization, and a nonsignificant reduction in

institutionalization. Low quality evidence showed that patients admitted to a stroke unit had a significant


reduction in the combined outcome of death or dependency and length of hospital stay and a

nonsignificant reduction in the outcome of dependency.


Plain Language Summary

A stroke is a sudden loss of brain function caused by interrupted blood flow to the brain or ruptured blood

vessels in the brain. A stroke unit is a hospital ward dedicated to caring for people who have had a stroke.

Nurses, doctors, and therapists who are experts in stroke provide care and work as a team. Not all

hospitals have a stroke unit. In these hospitals, care is provided in a general medical ward. This review

looked at how treatment in a stroke unit compares with treatment in a general medical ward. We looked at

11 studies involving 2,268 participants and found that patients who receive care in a stroke unit are more

likely to survive and less likely to need long-term care. They also have shorter hospital stays.


Table of Contents

List of Tables ............................................................................................................................................... 8

List of Figures .............................................................................................................................................. 9

List of Abbreviations ................................................................................................................................ 10

Background ............................................................................................................................................... 11 Objective of Analysis .................................................................................................................................................. 11 Clinical Need and Target Population ........................................................................................................................... 11

Description of Condition..................................................................................................................................... 11 Prevalence and Incidence ................................................................................................................................... 11 Ontario Context .................................................................................................................................................. 11

Technology/Technique ................................................................................................................................................ 11

Evidence-Based Analysis .......................................................................................................................... 13 Research Question ....................................................................................................................................................... 13 Research Methods........................................................................................................................................................ 13

Literature Search ................................................................................................................................................ 13 Inclusion Criteria ................................................................................................................................................ 13 Exclusion Criteria ............................................................................................................................................... 13 Outcomes of Interest ........................................................................................................................................... 13

Statistical Analysis ...................................................................................................................................................... 14 Quality of Evidence ..................................................................................................................................................... 14 Results of Evidence-Based Analysis ........................................................................................................................... 15

Meta-analysis ...................................................................................................................................................... 22

Conclusions ................................................................................................................................................ 27

Existing Guidelines for Technology......................................................................................................... 28

Acknowledgements ................................................................................................................................... 30

Appendices ................................................................................................................................................. 32 Appendix 1: Literature Search Strategies .................................................................................................................... 32 Appendix 2: Evidence Quality Assessment ................................................................................................................. 36

References .................................................................................................................................................. 38


List of Tables

Table 1: Body of Evidence Examined According to Study Design ............................................................ 16 Table 2: Citation Status ............................................................................................................................... 17 Table 3: Characteristics of Studies Included for Analysis .......................................................................... 18 Table 4: Proportion of Stroke Types Included in Studies ........................................................................... 19 Table 5: Process Characteristics of Stroke Units ........................................................................................ 21 Table A1: GRADE Evidence Profile for Comparison of Stroke Units With General Medical Wards....... 36 Table A2: Risk of Bias Among Randomized Controlled Trials for the Comparison of Stroke Units

With General Medical Wards ........................................................................................................ 37


List of Figures

Figure 1: Citation Flow Chart ..................................................................................................................... 15 Figure 2: Death ........................................................................................................................................... 22 Figure 3: Death or Institutionalization ........................................................................................................ 23 Figure 4: Institutionalization ....................................................................................................................... 23 Figure 5: Death or Dependency .................................................................................................................. 24 Figure 6: Dependency ................................................................................................................................. 25 Figure 7: Length of Hospital Stay ............................................................................................................... 26


List of Abbreviations

GRADE Grading of Recommendations Assessment, Development and Evaluation

RCT Randomized controlled trial

TIA Transient ischemic attack


Background

Objective of Analysis

The objective of this evidence-based analysis was to determine the effectiveness of a stroke unit

compared with a general medical ward for the management of stroke.

Clinical Need and Target Population

Description of Condition

A stroke is a sudden loss of brain function caused by interruption of blood flow to the brain (ischemic

stroke) or rupture of blood vessels within the brain (hemorrhagic stroke). Stroke can affect many

functions, including the ability to move, see, remember, speak, reason, read, and write. (1) Approximately

80% of strokes are ischemic, and 20% are hemorrhagic. (1)

A transient ischemic attack (TIA), also known as a mini-stroke, is caused by a temporary interruption of

blood flow to the brain. A TIA is an important warning sign that individuals are at increased risk of a

complete stroke. (1)

Prevalence and Incidence

Stroke is the leading cause of adult neurologic disability in Canada; about 300,000 people (1% of the

population) live with its effects. (2)

In 2009, 10,238 men and 9,764 women presented to an emergency department in Ontario with a stroke or

TIA. (3) The mean age was 72 years; more than half were between 66 and 84 years of age. Thirty-seven

percent had a TIA, 5% had an ischemic stroke, and 9% had a hemorrhagic stroke; in 50%, the stroke type

could not be determined. (3) About 1 in 3 stroke and TIA patients seeks medical attention within 2.5

hours of stroke onset. (3)

Ontario Context

In 2008/2009, 30.3% of patients admitted to hospital with stroke or TIA spent some part of their hospital

stay in a stroke unit. (3) This represents an increase from 2.7% in 2002/2003 and 18.6% in 2004/2005. (3)

Technology/Technique

A stroke unit is a geographically discrete area in a hospital and comprises a multidisciplinary team of

stroke care specialists who provide a complex package of care exclusively to persons who have had a

stroke. (4) A stroke unit can be classified as acute, rehabilitation, or comprehensive (combines both acute

and rehabilitation services). (4) Acute stroke units can be further classified as intensive, semi-intensive, or

non-intensive. An intensive stroke unit has continuous monitoring, high nurse staffing levels, and life-

support services. A semi-intensive stroke unit is similar to an intensive stroke unit, but without life-

support capabilities. A non-intensive stroke unit has none of the features of intensive or semi-intensive

stroke units. (4)


Because a stroke unit is a complex organizational intervention, the key factors responsible for its

effectiveness remain unknown, but organizational structure and processes of care may have an influence.

(5) Consistent characteristics of a stroke unit include the following (5):

a multidisciplinary team

coordination of care through regular multidisciplinary meetings

comprehensive assessment of medical problems and impairments

disabilities; active physiological management

early mobilization and avoidance of bed rest

skilled nursing care

early setting of rehabilitation plans involving carers

early assessment

planning of discharge needs


Evidence-Based Analysis

Research Question

What is the effectiveness of a stroke unit compared with a general medical ward on system- and patient-

level outcomes for the management of stroke?

Research Methods

Literature Search

Search Strategy A preliminary literature search identified 1 Cochrane database systematic review (4) and 1 web-based

systematic review, (6) with literature search dates up to and including 2006 and 2011, respectively.

Another literature search was performed on December 6, 2011, using Ovid MEDLINE, Ovid MEDLINE

In-Process and Other Non-Indexed Citations, Ovid Embase, EBSCO Cumulative Index to Nursing &

Allied Health Literature (CINAHL), the Wiley Cochrane Library, and the Centre for Reviews and

Dissemination database, for studies published from January 1, 2006, to December 6, 2011. (Appendix 1

provides details of the search strategies.) Abstracts were reviewed by a single reviewer and, for those

studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined

for any additional relevant studies not identified through the search.

Inclusion Criteria

English-language full-text publications

published between January 1, 2006, and December 6, 2011

randomized controlled trials (RCTs), systematic reviews, and meta-analyses of RCTs

evaluation of organized stroke unit care based in a discrete ward with a dedicated stroke team

general medical ward as the comparator

adult population hospitalized for ischemic stroke

Exclusion Criteria

studies evaluating mobile stroke teams

non-RCT study designs

grey literature, including PhD theses, abstracts, and personal communications

Outcomes of Interest

death

death or institutionalization

institutionalization

death or dependency

dependency

length of hospital stay


Statistical Analysis

Where appropriate, a meta-analysis was undertaken for explicit outcomes to determine the pooled

estimate of effect of a stroke unit compared with a general medical ward, using Review Manager 5,

version 5.1.6. (7) Relative risk was used as the pooled summary estimate for binary data, and mean

difference was used for continuous data.

The degree of statistical heterogeneity among studies was assessed using the I2 statistic for each outcome.

A fixed- or random-effects model was used, following the guidance of the Cochrane handbook. (8) An I2

> 50% was considered to be substantial heterogeneity; in such cases, a subgroup analysis was undertaken

(8) comparing comprehensive stroke units and rehabilitation stroke units.

Quality of Evidence

The quality of the body of evidence for each outcome was examined according to the Grading of

Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. (9) The

overall quality was determined to be high, moderate, low, or very low using a step-wise, structural

methodology.

Study design was the first consideration; the starting assumption was that RCTs are high quality, whereas

observational studies are low quality. Five additional factors—risk of bias, inconsistency, indirectness,

imprecision, and publication bias—were then taken into account. Limitations in these areas resulted in

downgrading the quality of evidence. Finally, 3 main factors that may raise the quality of evidence were

considered: the large magnitude of effect, the dose response gradient, and any residual confounding

factors. (9) For more detailed information, please refer to the latest series of GRADE articles. (9)

As stated by the GRADE Working Group, the final quality score can be interpreted using the following

definitions:

High High confidence in the effect estimate—the true effect lies close to the estimate of the

effect

Moderate Moderate confidence in the effect estimate—the true effect is likely to be close to the

estimate of the effect, but may be substantially different

Low Low confidence in the effect estimate—the true effect may be substantially different

from the estimate of the effect

Very Low Very low confidence in the effect estimate—the true effect is likely to be substantially

different from the estimate of the effect


Results of Evidence-Based Analysis

The database search yielded 673 citations published between January 1, 2006, and December 6, 2011

(with duplicates removed). Articles were excluded based on information in the title and abstract. The full

texts of potentially relevant articles were obtained for further assessment. Figure 1 shows the breakdown

of when and for what reason citations were excluded from the analysis.

One study (a Cochrane systematic review) met the inclusion criteria. (4)

Figure 1: Citation Flow Chart

Abbreviation: RCT, randomized controlled trial.

Search results (excluding duplicates)

n = 673

Study abstracts reviewed n = 22

Full-text studies reviewed n = 8

Included Studies (1) Systematic reviews: n = 1

Additional citations identified n = 2a

Citations excluded based on title n = 651

Citations excluded based on abstract n = 14

Citations excluded based on full text n = 7

Reasons for exclusion

Abstract review: Excluded study type (n = 11), not relevant (n = 3)

Full text review: Excluded study type (n = 2), duplicate publication (n = 2), letter (n = 1), systematic review including RCT and non-RCT studies (n = 2)

aCitations excluded for the following reasons: non-RCT (n = 1), wrong intervention (n = 1)


For each included study, the study design was identified and is summarized below in Table 1, a modified

version of a hierarchy of study design by Goodman. (10) Table 1: Body of Evidence Examined According to Study Design

Study Design Number of Eligible Studies

RCT Studies

Systematic review of RCTs 1

Large RCT

Small RCT

Observational Studies

Systematic review of non-RCTs with contemporaneous controls

Non-RCT with non-contemporaneous controls

Systematic review of non-RCTs with historical controls

Non-RCT with historical controls

Database, registry, or cross-sectional study

Case series

Retrospective review, modelling

Studies presented at an international conference

Expert opinion

Total 1

Abbreviation: RCT, randomized controlled trial.


Because the identified systematic review was both comprehensive and current, we selected RCTs from

the review that met our inclusion criteria. Of the 31 studies included in the Cochrane review, 11 RCTs

met the inclusion criteria. Table 2 shows which reports were included or excluded and the reasons for

exclusion.

Table 2: Citation Status

Author, Year Status Reason for Exclusion

Indredavik et al, 1991 (11) Included —

Stevens et al, 1984 (12) Included —

Garraway et al, 1980 (13) Included —

Kaste et al, 1995 (14) Included —

Fagerberg et al, 2000 (15) Included —

Hankey et al, 1997 (16) Included —

Cabral et al, 2003 (17) Included —

Ma et al, 2004 (18) Included —

Juby et al, 1996 (19) Included —

Kalra et al, 1993 (20) Included —

Kalra et al, 1995 (21) Included —

Peacock et al, 1972 (22) Excluded Compared a mixed rehabilitation ward with a general medical ward

Patel et al, 2000 (23) Excluded Non-RCT

Svensson et al, date unknown (4) Excluded Grey literature

Sulter et al, 2003 (24) Excluded Compared a stroke care monitoring unit with a conventional stroke care unit

Gordon et al, 1966 (25) Excluded Evaluated the merits of a rehabilitation nurse on a general medical ward

Sivenius et al, 1985 (26) Excluded Compared intensity of treatment

Dey et al, 2005 (27) Excluded Evaluated a mobile stroke unit

Wood-Dauphinee et al, 1984 (28) Excluded Evaluated a mobile stroke unit

Feldman et al, 1962 (29) Excluded Compared a comprehensive rehabilitation program with a function-oriented medical program for people with hemiplegia or hemiparesis

Aitken et al, 1993 (30) Excluded Grey literature

Vemmos et al, 2001 (31) Excluded Abstract

Ronning et al, 1998 (32) Excluded Non-RCT

Kalra et al, 2000 (33) Excluded Evaluated a mobile stroke unit

Yagura et al, 2005 (34) Excluded Non-RCT

Cavallini et al, 2003 (35) Excluded Non-RCT

Von Arbin et al, 1980 (36) Excluded Non-RCT

Laursen et al, 1995 (37) Excluded Non-English publication

Illmavirta et al, 1994 (4) Excluded Grey literature

Strand et al, 1985 (38) Excluded Non-RCT

Hamrin, 1982 (39) Excluded Non-RCT

Abbreviations: RCT, randomized controlled trial.


The characteristics of the 11 RCTs included in this review are reported in Table 3.

Table 3: Characteristics of Studies Included for Analysis

Study Type of Stroke

Unit

Country Study Sample,

n

Mean Age,

y

Population Treatment Group Control Group

Follow-up

Stevens et al, 1984 (12)

R United Kingdom

228 NR Persons with hemiplegia from stroke and who had received preliminary treatment in other wards

Stroke rehabilitation ward General medical ward

12 months

Kalra et al, 1993 (20)

R United Kingdom

245 78 Patients with acute onset of neurologic deficit of vascular origin lasting > 24 hours

Stroke rehabilitation unit General medical ward

By discharge (13–105 days)

Kalra et al 1995 (21)

R United Kingdom

71 79 Patients with severe stroke and poor prognosis (median 9 days between stroke and randomization)

Stroke rehabilitation unit General medical ward

By discharge (16–126 days)

Juby et al, 1996 (19)

R United Kingdom

176 69 Patients with first or recurrent stroke within 5 weeks of admission to study

Stroke rehabilitation unit Conventional ward

3, 6, and 12 months

Hankey et al, 1997 (16)

NR Australia 59 70 Patients with stroke (cerebral infarction or haemorrhage) of < 7 days’ duration

Stroke unit General medical ward

6 months

Fagerberg et al, 2000 (15)

C Sweden 249 80 Persons ≥ 70 years with acute focal neurologic deficit of no apparent cause other than that of vascular origin ≤ 7 days before admission

Acute medical (75% of sample) or neurological (25% of sample) stroke unit integrated with continued geriatric stroke unit care after discharge

6 general medical wards

3 months and 1 year

Cabral et al, 2003 (17)

C Brazil 74 68 Persons with acute stroke (first or recurrent) within 7 days of admission

Acute and rehabilitation stroke unit

Multiple general medical wards

6 months

Ma et al, 2004 (18)

C China 392 62 Patients with acute focal neurologic defects caused by cerebral vessel disease and lasting > 24 hours


General medical ward

1 week, and at discharge (time NR)

Kaste et al, 1995 (14)

C Finland 243 73 Patients with ischemic cerebral infarctions (80%), TIA (6%), hemorrhagic (9%), or subarachnoid hemorrhage (4%)

Department of neurology (stroke unit)


12 months

Indredavik et al, 1991 (11)

C Norway 220 73 Patients with acute focal neurologic deficits of vascular origin lasting > 24 hours and presenting < 1 week to emergency

Stroke unit: geographically defined area designated for acute stroke patients; included acute medical and acute rehab treatment


6 and 52 weeks

Garraway et al, 1980 (13)

C Scotland 311 73 Persons 60 years of age and older with a focal neurologic deficit of presumed vascular origin for at least 6 hours but no longer than 3 days



12 months

Abbreviations: C, comprehensive stroke unit; NR, not reported; R, rehabilitation stroke unit; TIA, transient ischemic attack.


The proportion of persons with an ischemic or hemorrhagic stroke or TIA in each study is reported in Table 4.

Table 4: Proportion of Stroke Types Included in Studies

Type of Stroke Study

Stevens et al, 1984 (12)

Kalra et al, 1993

(20)

Kalra et al, 1995 (21)

Juby et al, 1996

(19)

Hankey et al, 1997

(16)

Fagerberg et al, 2000

(15)

Cabral et al, 2003

(17)

Ma et al,

2004 (18)

Kaste et al, 1995

(14)

Indredavik et al, 1991

(11)

Garraway et al,

1980 (13)

Ischemic, % NR NR 79 NR 86 92 NR 73 80 80 NR

Hemorrhagic, % NR NR 21 NR 14 4 NR 27 9 13 NR

TIA, % NR NR 0 NR 0 2 NR 0 6 3 NR

Other, % NR NR 0 NR 0 2 NR 0 4 4 NR

Abbreviations: NR, not reported; TIA, transient ischemic attack.


Indredavik et al (40) determined that 2 process characteristics of a stroke unit—early mobilization after

stroke and adequate systemic hydration—were significantly associated with the outcome of discharge

home within 6 weeks of stroke. Langhorne et al (5) identified 8 process characteristics of a stroke unit:

multidisciplinary team

co-ordinated care through regular multidisciplinary team meetings

comprehensive assessment of medical problems, impairments, and disabilities

active physiological management (careful management of physiological abnormalities)

early mobilization and avoidance of bed rest

skilled nursing care

early setting of rehabilitation plans involving carers

early assessment and planning of discharge needs

The 11 studies included in this report were evaluated for inclusion of the above 8 process characteristics

in the stroke unit treatment groups (Table 5). A majority of studies included a multidisciplinary team, co-

ordinated care through regular multidisciplinary team meetings, and early setting of rehabilitation plans

involving carers. However, many of the process characteristics were not reported in the 11 studies

(indicated by x); it is unknown whether these characteristics were part of care in the stroke units studied.


Table 5: Process Characteristics of Stroke Units

Stroke Unit

Author, Year Multi-disciplinary

Team

Coordinated Care Through Regular Team

Meetings

Comprehensive Assessment of

Medical Problems, Impairments, and

Disabilities

Active Physiological Management

Early Mobilization

and Avoidance of Bed Rest

Skilled Nursing

Care

Early Setting of

Rehabilitation Plans

Involving Carers

Early Assessment

and Planning of Discharge

Needs

R Stevens et al, 1984 (12) x x x x x

R Kalra et al, 1993 (20) x x x x x

R Kalra et al, 1995 (21) x x x x

R Juby et al, 1996 (19) x x x x

NR Hankey et al, 1997 (16) x x x x

C Fagerberg et al, 2000 (15) x

C Cabral et al, 2003 (17) x x x

C Ma et al, 2004 (18) x x x x x

C Kaste et al, 1995 (14) x x x

C Indredavik et al, 1991 (11) x x x x

C Garraway et al, 1980 (13) x x x x x x x x

Total 10 9 5 4 1 2 7 4

Abbreviations: C, comprehensive stroke unit; NR, not reported; R, rehabilitation stroke unit.

Process characteristic present.

x Not mentioned in manuscript text.


Meta-analysis

A meta-analysis was undertaken to evaluate the following outcomes: death, death or institutionalization,

institutionalization, death or dependency, dependency, and length of hospital stay. For each outcome, the

results of 11 studies were combined to derive pooled estimates of effect, and a random effects model was

used to generate relative risk summary statistics for patients treated in stroke units versus those treated in

general medical wards.

Death There was a significant relative risk reduction of 19% in death in persons admitted to a stroke unit

compared with those admitted to a general medical ward (Figure 2). The I2 value was 0%, indicating no

heterogeneity among studies, so a subgroup analysis was not completed. The quality of evidence was

moderate.

Figure 2: Death

Abbreviations: CI, confidence interval; df, degrees of freedom; GMW, general medical ward; I2, index of heterogeneity; M-H, Mantel-Haenszel.


Death or Institutionalization There was a significant relative risk reduction of 20% in death or institutionalization in persons admitted

to a stroke unit compared with those admitted to a general medical ward (Figure 3). The I2 value was 0%,

indicating no heterogeneity among studies, so a subgroup analysis was not completed. The quality of

evidence was moderate.

Figure 3: Death or Institutionalization


Institutionalization There was a nonsignificant relative risk reduction of 21% in institutionalization in persons admitted to a

stroke unit compared with those admitted to a general medical ward (Figure 4). The I2 value was 23%,

indicating low heterogeneity among studies, so a subgroup analysis was not completed. The quality of

evidence was moderate.

Figure 4: Institutionalization



Death or Dependency There was a significant relative risk reduction of 13% in death or dependency in persons admitted to a

stroke unit compared with those admitted to a general medical ward (Figure 5). The I2 value was 77%,

indicating significant heterogeneity among studies. Subgroup analyses were completed, but results were

nonsignificant and did not reduce heterogeneity. The quality of evidence was low.

Figure 5: Death or Dependency



Dependency There was a nonsignificant relative risk reduction of 10% in dependency in persons admitted to a stroke

unit compared with those admitted to a general medical ward (Figure 6). The I2 value was 61%, indicating

significant heterogeneity among studies. Subgroup analyses were completed, but results were

nonsignificant and did not reduce heterogeneity. The quality of evidence was low.

Figure 6: Dependency



Length of Hospital Stay There was a significant reduction in length of stay of 12 days for persons admitted to a stroke unit

compared with those admitted to a general medical ward (Figure 7). The I2 value was 90%, indicating

significant heterogeneity among studies. Subgroup analyses were completed, and there was a significant

reduction in length of stay in studies evaluating comprehensive stroke units, but a nonsignificant

reduction in studies evaluating a rehabilitation stroke units. Significant heterogeneity remained in all

subgroup analyses. The quality of evidence was low.

Figure 7: Length of Hospital Stay



Conclusions

Moderate quality evidence showed that persons admitted to a stroke unit had a significant reduction in

death and the combined outcome of death or institutionalization, and a nonsignificant reduction in

institutionalization. Low quality evidence showed that patients admitted to a stroke unit had a significant

reduction in the combined outcome of death or dependency and length of hospital stay and a

nonsignificant reduction in the outcome of dependency.


Existing Guidelines for Technology

Canadian Stroke Strategy

The Canadian Stroke Strategy Canadian Best Practice Recommendations for Stroke Care 2010, (41) a

joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada,

recommends that patients admitted to hospital because of an acute stroke or transient ischemic attack be

treated in an interprofessional stroke unit.

Patients should be admitted to a stroke unit which is a specialized, geographically defined

hospital unit dedicated to the management of stroke patients. (41)

The core interprofessional team on the stroke unit should consist of healthcare professionals with

stroke expertise from medicine, nursing, occupational therapy, physiotherapy, speech-language

pathology, social work, and clinical nutrition. Additional disciplines may include pharmacy,

(neuro) psychology, and recreation therapy. (41)

Further guideline recommendations suggest that all patients with stroke who are admitted to hospital and

who require rehabilitation be treated in a comprehensive or rehabilitation stroke unit by an

interdisciplinary team. (41)

Ontario Stroke System

The Ontario Stroke System Consensus Panel on the Stroke Rehabilitation System 2007 (42) recommends

that all stroke survivors who would benefit from inpatient stroke rehabilitation be treated in a stroke

rehabilitation unit or geographically defined unit with a stimulating environment.

Ontario Stroke Evaluation Report

The Institute for Clinical Evaluative Sciences Ontario Stroke Evaluation Report 2011 (3) recommends

that acute stroke cases be treated by a team of experts, preferably in a dedicated unit. Expert care results

in reduced complications and decreased death and disability. As well, the report further recommends that

there be continued efforts to transport persons with stroke to hospitals with specialized stroke units

(designated stroke centres) to sustain the trend of reduced mortality due to stroke. (3)

Brain Attack Coalition

Guidelines about stroke units from the U.S. Brain Attack Coalition (43) include the following:

There is an abundance of evidence to support the efficacy of stroke units in the care of persons

with acute stroke. It is recommended that a stroke unit include continuous multichannel telemetry

capable of monitoring blood pressure, pulse, respirations, and oxygenation. There should be

written protocols that detail how changes in a patients’ status are detected, how they are

documented, and how medical staff are notified of such changes. Protocols of notification of

medical staff of any changes in vital signs and/or neurological status should be specified. (43)


American Stroke Association

Recommendations from the American Stroke Association Task Force on the Development of Stroke

Systems include the following: “a stroke system should use organized approaches (e.g. stroke teams,

stroke units, and written protocols) to ensure that all patients receive appropriate sub acute care.” (44)


Acknowledgements

Editorial Staff Jeanne McKane, CPE, ELS(D)

Elizabeth Jean Betsch, ELS

Medical Information Services Kellee Kaulback, BA(H), MISt

Health Quality Ontario’s Expert Panel on Stroke Units

Name Role Organization

Dr. Mark Bayley

Medical Director,

Brain and Spinal Cord Rehab Program

UHN Toronto Rehab and Department of Medicine, University of Toronto

Ms. Christina O’Callaghan

Executive Director Ontario Stroke Network

Dr. Gustavo Saposnik

Director, Stroke Outcomes Research Centre,

Associate Professor of Medicine,

Division of Neurology, St. Michael’s Hospital

Institute for Clinical Evaluative Sciences,

University of Toronto

Dr. Richard Swartz

Director,

University of Toronto Stroke Program

Medical Director, NE-GTA Regional Stroke Program,

Associate Professor, Division of Neurology,

Department of Medicine,

Sunnybrook Health Sciences Centre,


Dr. Robert Teasell

Professor of Physical Medicine and Rehabilitation,

Schulich School of Medicine

Western University

Lawson Research Institute

St. Joseph’s Health Care London

Dr. Paul E. Cooper Senior Medical Director – Medicine,

Chief, Department of Clinical Neurological Sciences

London Health Sciences Centre

Dr. Paul Ellis Emergency Physician University Health Network

Dr. Andrew Samis

Physician Stroke Champion and Staff Intensivist,

Division of Critical Care

Quinte Health Care,

Belleville Ontario

Dr. Moira Kapral

Division of General Internal Medicine & Clinical Epidemiology,

Associate Professor, Department of Medicine,

Scientist


Institute for Clinical Evaluative Sciences (ICES)

Dr. Murray Krahn

Director, THETA,

F. Norman Hughes Chair and Professor,

Department of Medicine and Faculty of Pharmacy


Dr. Daniel Brouillard Internist / Stroke Survivor Kingston Heart Clinic


Name Role Organization

Dr. R. Loch MacDonald

Keenan Endowed Chair in Surgery

Head, Division of Neurosurgery,

Professor of Surgery,


St. Michael’s Hospital

Dr. Ruth Hall OSN Evaluation Lead and Adjunct Scientist Ontario Stroke Network,

Institute for Clinical Evaluative Sciences

Linda Kelloway Best Practices Leader Ontario Stroke Network

Rhonda Whiteman

Clinical Nurse Specialist,

Stroke Best Practice Coordinator

Hamilton Health Sciences Centre

Rebecca Fleck

Occupational Therapist,

Regional Stroke Education and Research Coordinator,

Central South Regional Stroke Network

Hamilton Health Sciences Centre

Deborah Willems

Regional Rehabilitation Coordinator,

Southwestern Ontario Stroke Network

London Health Sciences Centre

Holly Sloan

Speech–Language Pathologist Trillium Health Centre Site,

Credit Valley Hospital and Trillium Health Centre

Matthew Meyer

Research Coordinator,

PhD Candidate,

Epidemiology and Biostatistics

OSN & Lawson Health Research Institute, Schulich School of Medicine and Dentistry, Western University

Kathleen Lee Social Worker Health Sciences North

Linda Welham

Professional Resource,

Case Costing and Decision Support

Southlake Regional Health Centre

Lori Marshall Executive Vice President,

Strategy, Performance and Aboriginal Health

Thunder Bay Regional Health Sciences Centre

Jin-Hyeun Huh

Pharmacy Director of Inpatient Operations,

Department of Pharmacy

University Health Network

Derek Leong

Clinical Pharmacist,

General Internal Medicine

University Health Network – Toronto General Hospital

Ministry Representatives

Peter Biasucci Manager, Acute and Rehabilitative Care Unit,

Health Policy and Care Standards Branch,

Health System Strategy and Policy Division

Ministry of Health and Long-Term Care

Jason Lian

Senior Methodologist, Health System Funding Policy Branch


Thomas Smith

Acting Program Manager,

Provincial Programs Branch



Appendices

Appendix 1: Literature Search Strategies

Stroke Units – Stroke MEGA Literature Search

Search date: December 5-6, 2011

Databases searched: OVID MEDLINE, OVID MEDLINE In-Process and Other Non-Indexed Citations,

OVID EMBASE, Wiley Cochrane, EBSCO CINAHL, Centre for Reviews and Dissemination.

Database: Ovid MEDLINE(R) <1948 to November Week 3 2011>, Ovid MEDLINE(R) In-Process &

Other Non-Indexed Citations <December 05, 2011>, Embase <1980 to 2011 Week 48>

1 exp Stroke/ or exp brain ischemia/ (273524)

2 exp intracranial hemorrhages/ use mesz (50434)

3 exp brain hemorrhage/ use emez (66291)

4 exp stroke patient/ use emez (5349)

5 (stroke or tia or transient ischemic attack or cerebrovascular apoplexy or cerebrovascular accident or

cerebrovascular infarct* or brain infarct* or CVA or brain ajd2 isch?emia or (cerebral adj2 isch?emia) or

(intracranial adj2 hemorrhag*) or (brain adj2 hemorrhag*)).ti,ab. (320222)

6 or/1-5 (509939)

7 exp Hospital Units/ use mesz (67581)

8 exp Stroke Unit/ use emez (1106)

9 exp Skilled Nursing Facilities/ use mesz (3429)

10 ((stroke adj2 ward*) or (stroke adj2 unit*)).ti,ab. (4568)

11 exp Patient Care Team/ use mesz (49228)

12 Cooperative Behavior/ or exp Interprofessional Relations/ or exp Interinstitutional Relations/ use

mesz (140691)

13 exp Nursing, Team/ use mesz (1985)

14 exp "Delivery of Health Care, Integrated"/ use mesz (6935)

15 exp interdisciplinary communication/ (12406)

16 exp TEAM NURSING/ use emez (20)

17 exp Cooperation/ use emez (31785)

18 exp TEAMWORK/ use emez (9089)

19 exp Integrated Health Care System/ use emez (4946)

20 ((transitional or multidisciplin* or multifacet* or multi-disciplin* or multi-facet* or cooperat* or co-

operat* or interdisciplin*or inter-disciplin* or collaborat* or multispecial* or multi-special* or share or

sharing or shared or integrat* or joint or multi-modal or multimodal) adj2 (care or team*)).ti,ab. (41141)

21 or/7-20 (308326)

22 6 and 21 (7619)

23 limit 22 to english language (6333)

24 limit 23 to english language (6333)

25 limit 24 to yr="2006 -Current" (3522)

26 limit 25 to (meta analysis or randomized controlled trial) (198)

27 exp Technology Assessment, Biomedical/ or exp Evidence-based Medicine/ use mesz (64387)

28 exp Biomedical Technology Assessment/ or exp Evidence Based Medicine/ use emez (516761)

29 (health technology adj2 assess$).ti,ab. (3051)

30 exp Random Allocation/ or exp Double-Blind Method/ or exp Control Groups/ or exp Placebos/ use

mesz (379825)


31 Randomized Controlled Trial/ or exp Randomization/ or exp RANDOM SAMPLE/ or Double Blind

Procedure/ or exp Triple Blind Procedure/ or exp Control Group/ or exp PLACEBO/ use emez (900712)

32 (random* or RCT).ti,ab. (1256903)

33 (placebo* or sham*).ti,ab. (415406)

34 (control* adj2 clinical trial*).ti,ab. (35211)

35 meta analysis/ use emez (57708)

36 (meta analy* or metaanaly* or pooled analysis or (systematic* adj2 review*) or published studies or

published literature or medline or embase or data synthesis or data extraction or cochrane).ti,ab. (252661)

37 or/26-36 (2165215)

38 25 and 37 (623)

39 remove duplicates from 38 (471)

CINAHL

# Query Results

S25 S21 AND S24

Limiters - Published Date from: 20060101-20111231 108

S24 S22 or S23 154009

S23

random* or sham*or rct* or health technology N2 assess* or meta analy* or metaanaly* or

pooled analysis or (systematic* N2 review*) or published studies or medline or embase or

data synthesis or data extraction or cochrane or control* N2 clinical trial*

145959

S22

(MH "Random Assignment") or (MH "Random Sample+") or (MH "Meta Analysis") or

(MH "Systematic Review") or (MH "Double-Blind Studies") or (MH "Single-Blind

Studies") or (MH "Triple-Blind Studies") or (MH "Placebos") or (MH "Control

(Research)")

82705

S21 S6 and S20 1793

S20 (S7 or S8 or S9 or S10 or S11 or S12 or S13 or S14 or S15 or S16 or S17 or S18 or S19) 66643

S19 (MH "Nurse Liaison") OR "liaison" 1815

S18 (MH "Collaboration") 16613

S17 (MH "Interinstitutional Relations") 5409

S16 (MH "Interprofessional Relations+") 13700

S15

transitional N2 care or multidisciplin* N2 care or multifacet* N2 care or multi-disciplin*

N2 care or multi-facet* N2 care or cooperat* N2 care or co-operat* N2 care or

interdisciplin* N2 care or inter-disciplin* N2 care or collaborat* N2 care or multispecial*

N2 care or multi-special* N2 care or share N2 care or sharing N2 care* or shared N2 care

or integrat* N2 care or joint N2 care or multi-modal N2 care or multimedia N2 care or

speciali* N2 care or dedicated N2 care

29186

S14

transitional N2 team* or multidisciplin* N2 team* or multifacet* N2 team* or multi-

disciplin* N2 team* or multi-facet* N2* team* or cooperat* N2 team* or co-operat* N2

team* or interdisciplin* N2 team* or inter-disciplin* N2 team* or collaborat* N2 team* or

multispecial* N2 team* or multi-special* N2 team* or share N2 team* or sharing N2 team*

or shared N2 team* or integrat* N2 team* or joint N2 team* or multi-modal N2 team* or

multimedia N2 team* or speciali* N2 team* or dedicated N2 team*

21828

S13 (MH "Health Care Delivery, Integrated") 3205

S12 (MH "Team Nursing") 315


S11 (MH "Cooperative Behavior") 2341

S10 (MH "Multidisciplinary Care Team+") 17796

S9 (stroke N2 ward*) or (stroke N2 unit*) 1022

S8 (MH "Skilled Nursing Facilities") 1644

S7 (MH "Stroke Units") 210

S6 S1 OR S2 OR S3 OR S4 OR S5 42479

S5 (MH "Stroke Patients") 1812

S4

stroke or tia or transient ischemic attack or cerebrovascular apoplexy or cerebrovascular

accident or cerebrovascular infarct* or brain infarct* or CVA or brain N2 isch?emia or

cerebral N2 isch?emia or intracranial N2 hemorrhag* or brain N2 hemorrhag*

38045

S3 (MH "Intracranial Hemorrhage+") 4609

S2 (MH "Cerebral Ischemia+") 5334

S1 (MH "Stroke") 24768

Cochrane

ID Search Hits

#1 MeSH descriptor Stroke explode all trees 3785

#2 MeSH descriptor Brain Ischemia explode all trees 1862

#3 MeSH descriptor Intracranial Hemorrhages explode all trees 1080

#4

(stroke or tia or transient ischemic attack or cerebrovascular apoplexy or

cerebrovascular accident or cerebrovascular infarct* or brain infarct* or CVA

or (brain NEAR/2 isch?emia) or (cerebral NEAR/2 isch?emia) or (intracranial

NEAR/2 hemorrhag*) or (brain NEAR/2 hemorrhag*)):ti or (stroke or tia or

transient ischemic attack or cerebrovascular apoplexy or cerebrovascular

accident or cerebrovascular infarct* or brain infarct* or CVA or (brain

NEAR/2 isch?emia) or (cerebral NEAR/2 isch?emia) or (intracranial NEAR/2

hemorrhag*) or (brain NEAR/2 hemorrhag*)):ab

15916

#5 (#1 OR #2 OR #3 OR #4) 17546

#6 MeSH descriptor Hospital Units explode all trees 2391

#7 MeSH descriptor Skilled Nursing Facilities explode all trees 46

#8 ((stroke NEAR/2 ward*) or (stroke NEAR/2 unit*)):ti and ((stroke NEAR/2

ward*) or (stroke NEAR/2 unit*)):ab

50

#9 MeSH descriptor Patient Care Team explode all trees 1130

#10 MeSH descriptor Cooperative Behavior explode all trees 459

#11 MeSH descriptor Nursing, Team explode all trees 18

#12 MeSH descriptor Delivery of Health Care, Integrated explode all trees 159

#13 MeSH descriptor Interdisciplinary Communication explode all trees 79

#14

((transitional or multidisciplin* or multifacet* or multi-disciplin* or multi-

facet* or cooperat* or co-operat* or interdisciplin*or inter-disciplin* or

collaborat* or multispecial* or multi-special* or share or sharing or shared or

179

http://onlinelibrary.wiley.com.myaccess.library.utoronto.ca/o/cochrane/searchHistory?mode=runquery&qnum=1

























integrat* or joint or multi-modal or multimodal) NEAR/2 (care or team*)):ti

and ((transitional or multidisciplin* or multifacet* or multi-disciplin* or

multi-facet* or cooperat* or co-operat* or interdisciplin*or inter-disciplin* or

collaborat* or multispecial* or multi-special* or share or sharing or shared or

integrat* or joint or multi-modal or multimodal) NEAR/2 (care or team*)):ab

#15 MeSH descriptor Interinstitutional Relations explode all trees 39

#16 MeSH descriptor Interprofessional Relations explode all trees 281

#17 (#6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15

OR #16)

4299

#18 (#5 AND #17), from 2006 to 2011 54

Centre for Reviews and Dissemination

Line Search Hits

1 MeSH DESCRIPTOR stroke EXPLODE ALL TREES 549

2 MeSH DESCRIPTOR brain ischemia EXPLODE ALL TREES 144

3 MeSH DESCRIPTOR intracranial hemorrhages EXPLODE ALL

TREES 116

4

((stroke or tia or transient ischemic attack or cerebrovascular

apoplexy or cerebrovascular accident or cerebrovascular infarct* or

brain infarct* or CVA or brain ajd2 isch?emia or (cerebral adj2

isch?emia) or (intracranial adj2 hemorrhag*) or (brain adj2

hemorrhag*)))

2108

5 #1 OR #2 OR #3 OR #4 2195

6 MeSH DESCRIPTOR Hospital Units EXPLODE ALL TREES 403

7 MeSH DESCRIPTOR Skilled Nursing Facilities EXPLODE ALL

TREES 8

8 (((stroke adj2 ward*) or (stroke adj2 unit*))) 63

9 MeSH DESCRIPTOR Patient Care Team EXPLODE ALL TREES 193

10 MeSH DESCRIPTOR Cooperative Behavior EXPLODE ALL

TREES 32

11 MeSH DESCRIPTOR Nursing, Team EXPLODE ALL TREES 3

12 MeSH DESCRIPTOR Delivery of Health Care, Integrated

EXPLODE ALL TREES 47

13 MeSH DESCRIPTOR interdisciplinary communication EXPLODE

ALL TREES 17

14 MeSH DESCRIPTOR Interinstitutional Relations EXPLODE ALL

TREES 5

15 MeSH DESCRIPTOR interprofessional relations EXPLODE ALL

TREES 39

16

(((transitional or multidisciplin* or multifacet* or multi-disciplin* or

multi-facet* or cooperat* or co-operat* or interdisciplin*or inter-

disciplin* or collaborat* or multispecial* or multi-special* or share

or sharing or shared or integrat* or joint or multi-modal or

multimodal) adj2 (care or team*)))

515

17 #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14

OR #15 OR #16 1108

18 #5 AND #17 92

19 (#5 and #18) FROM 2006 TO 2011 40












Appendix 2: Evidence Quality Assessment

Table A1: GRADE Evidence Profile for Comparison of Stroke Units With General Medical Wards

Number of Studies (Design)

Risk of Bias Inconsistency Indirectness Imprecision Publication Bias Upgrade Considerations

Quality

Death

11 RCTs Serious limitations (−1)a

No serious limitations



Undetected

None ⊕⊕⊕ Moderate

Death or Institutionalization





Undetected


Institutionalization





Undetected


Death or Dependency

11 RCTs Serious limitations (−1)b

Serious limitations (−1)c



Undetected

None ⊕⊕ Low

Dependency





Undetected

None ⊕⊕ Low

Length of Hospital Stay





Undetected

None ⊕⊕ Low

Abbreviations: GRADE, Grading of Recommendations Assessment, Development and Evaluation; RCT, randomized controlled trial. a 54% of studies had unclear treatment allocation concealment. b Lack of concealment and blinding. c I2 > 50%.


Table A2: Risk of Bias Among Randomized Controlled Trials for the Comparison of Stroke Units With General Medical Wards

Author, Year Allocation Concealment

Blinding Complete Accounting of Patients and

Outcome Events

Selective Reporting

Bias

Baseline Characteristics

Comparable

Randomization Methods

Sample Size Calculation

Intention to Treat Analysis

Stevens et al, 1984 (12) No limitations Limitationsa No limitations No limitations No limitations No limitations Limitationsb Limitationsc

Kalra et al, 1993 (20) Limitationsa Limitationsd No limitations No limitations No limitations Limitationsa Limitationsa No limitations

Kalra et al, 1995 (21) No limitations Limitationse No limitations No limitations No limitations No limitations Limitationsb No limitations

Juby et al, 1996 (19) Limitationsa No limitations No limitations No limitations Limitationsf No limitations Limitationsb Limitationsc

Hankey et al, 1997 (16) Limitationsa No limitations No limitations No limitations Limitationsg No limitations Limitationsc No limitations

Fagerberg et al, 2000 (15) No limitations No limitations No limitations No limitations Limitationsh No limitations Limitations No limitations

Cabral et al, 2003 (17) Limitationsa No limitations No limitations No limitations No limitations No limitations Limitationsb No limitations

Ma et al, 2004 (18) Limitationsa Limitationsd No limitations No limitations Limitationsi No limitations Limitationsb No limitations

Kaste et al, 1995 (14) No limitations Limitationsa No limitations No limitations Limitationsj No limitations Limitationsc Limitationsc

Indredavik et al, 1991 (11) No limitations Limitationsk No limitations No limitations No limitations No limitations Limitationsb No limitations

Garraway et al, 1980 (13) Limitationsa Limitationsa No limitations No limitations No limitations No limitations Limitationsb Limitationsc

Abbreviations: CI, confidence interval; OR, odds ratio. aUnclear methods. bNot reported. cNot done dNot done; staff on both stroke unit and general medical ward unaware of study. eConsultant on stroke rehabilitation unit not blinded. fGreater proportion of women in stroke unit (P = 0.04).

gGreater proportion of persons with lacunar syndrome in stroke unit (OR, 2.6; 95% CI, 0.86–7.6) and had absent or mild weakness (OR, 2.9; 95% CI, 0,98–8.4). hGreater proportion of persons with angina pectoris in the stroke (P = 0.04). iBarthel Index greater in persons admitted to stroke unit (P = 0.01). jGreater proportion of persons with cardiac disorder in stroke unit. kOutcome assessors not blinded.


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Effectiveness of Stroke Unit Care: A Special Report · Effectiveness of Stroke Unit Care: A Special Report. October 2014; pp. 1–42 6 Plain Language Summary A stroke is a sudden